A recent systematic review of alcohol brief interventions looked specifically at whether the ‘setting, practitioner group and content matter?’. Based on data from 52 research trials, the results conclude that alcohol brief interventions ‘play a small but significant role in reducing alcohol consumption’ – but also identifies some differences based on where and by whom.

Perhaps the most significant finding is that IBA delivered by nurses were found to be most effective. This may be seen as promising given the reach of nurses and recognition of the role of IBA in healthcare settings. However the study cannot tell us how much this finding may be as a result of the way in which nurses deliver the intervention versus other factors such as nurses being seen as a credible person to offer alcohol advice.

As such it suggests nurses should be seen as a priority for the delivery of IBA, with efforts needed to address key barriers of time, worry about losing trust of the patient and inadequate training. It also emphasises previous research suggesting ‘a good relationship between the practitioner and the client’ as an important factor.

The findings also suggest the less intensive approach of ‘brief advice’ was found more effective than longer motivational interviewing interventions. However concerns over ‘brief advice’ being interpreted as simply feedback and a leaflet -rather than say 5-10 minutes structured advice – should be noted.

Another key finding was that when comparing settings, universities were found to have the greatest effect size alongside primary care – surprising given the limited level of attention to IBA in universities. Perhaps another unexpected findings was a lack of evidence for IBA in A&E settings. Whilst previous studies have found small effects, the review suggests that the specific time pressures within A&Es, lack of privacy and seriousness of injuries may be significant in hampering its value as a setting.

The authors rightly highlight limitations to the research and caution over drawing firm conclusions about role and settings. However it may be fair to summarise that it strengthens the case for shorter ‘brief advice’ to be delivered by nurses in particular. In addition, further focus on the potential of universities as a setting for delivery may also be an important area for development. Meanwhile the possibly limited benefits of IBA delivery in busy A&E settings may need to be weighed up against the level of effort required.

Results from the 2015 British Social Attitudes (BSA) were recently released, revealing the vast majority of patients felt either fairly (20%) or very comfortable (75%) talking to their doctor about their alcohol consumption.

Just 2% of respondents were either fairly or very uncomfortable doing so, suggesting there is little justification for the commonly perceived barrier that patients may be defensive when offered brief intervention. A further 3% said they did not feel either comfortable or not.

Furthermore over four-fifths (85%) of people say that they “would answer completely honestly”, while 14% say that they would “bend the truth a little”. Whilst the study found people were more likely so say they would answer honestly if they didn’t drink or were lower risk drinkers, 62% of risky drinkers still said they would be truthfull.

Despite such a high percentage of patients being comfortable to discuss their alcohol use, it is important to note that how such questions – and any subsequent ‘advice’ – is carried out is crucial to the effectiveness of brief intervention.

One of the most important things is to ensure patients do not feel they are being judged or picked out individually for alcohol questions. Whilst many practices screen patients at certain points, initiating IBA can be done whenever a spare moment arises.

Patients of course do have the right to decline, and any following conversation should not be pushy or lecturing. Delivering a validated alcohol assessment such as the AUDIT and offering brief feedback on the person’s score appear to be the most important elements – Primary Care roles musn’t think that patients are against this.

A new document outlining the evidence for IBA and standards for delivery in a range of settings has been released. Commissioned by the Safe Sociable London Partnership, the document provides an overview of the evidence base for IBA as a short ‘brief intervention’, and suggests how it should be delivered in key community health settings.

‘Identification and Brief Advice’ has been central to England’s alcohol policy, particularly given its effectiveness in comparison to other individual level interventions. Brief intervention is most likely to ‘work’ because a combination of ‘identifying’ a level of risk – and ‘feedback’ to the drinker to inform them of this – may trigger a process of change.

In contrast, just handing someone a booklet means even if it is read, a risky drinker may not realise the information is relevant to them and assume they are fine. Brief advice may also give added benefits, such as helping build a person’s motivation or belief in their ability to change.

As such, the guides summarises the evidence base behind IBA, for example it states:

“On average, following intervention, individuals reduced their drinking by 15%. While this maynot be enough to bring the individual’s drinking down to lower risk levels, it will reduce theiralcohol-related hospital admissions by 20% and “absolute risk of lifetime alcohol-related death by some 20%” as well as have a significant impact on alcohol–related morbidity.”

As well as setting out an interpretation of how IBA should be delivered, it provides specific suggestions and statements for key community health roles including:

Primary Care Staff

Community Pharmacists

Midwives and Health Visitors

Mental Health Service Staff

Drug Service Staff

Delivery by Sexual Health Workers

The report also addresses the crucial issue of ‘making it happen’ through what it describes as ensuring ‘organisational ownership’, as well as the need for training, materials and inter-linking IBA with related issues and policy.

Some of the statements within the report will still be subject to debate. In particular, exactly what ‘brief advice’ consists of, and whether IBA should be implemented in all community health settings without more setting specific evidence.

Primary Care is the key setting for alcohol brief intervention or ‘IBA’. Most the evidence base revolves around delivery in Primary Care settings and in England ‘DES’ payments are made for new registrations screened (and then in theory offered brief intervention when appropriate). IBA is also is part of the NHS health checks being offered to all 40-74 year olds. But..

“Alcohol, OK, so you drink 20 drinks per week on average?” “Yes”. “Right, OK that’s around 20 units per week, which is within the government guidelines of 21 for men”

Whoops. That was from a Practice Nurse when I joined a new surgery not that long ago. Sadly, anecdotal reports of poor or simply incorrect IBA practices are not unusual from those who know what it should look like. But we have nothing else to go on other than ‘activity’ data to get a picture of what’s really going on.

In one local area, working with commissioners we attempted to get local practices to complete a short survey on their IBA delivery – about 8% responded. A subsequent proposal for a collaborative ‘mystery shopping’ approach, based on a successful pilot in sexual health settings, was rejected by the local medical committee – most members (yes some were GPs) didn’t support it. No alternative suggestions were offered though.

Not surprisingly, there can be a sense of despondency amongst those trying to raise the standard of Primary Care IBA. Is there any point in organising good IBA training, resources and pathways if there’s no interest in taking them up? If we can’t get it right in Primary Care, is there hope for any other settings?

Or perhaps there is more chance for IBA in other settings? The news is full of stories about General Practice in crisis. More doctors needed, less being spent, more demand and an ageing population – I’m not going to argue Primary Care isn’t under a lot of pressure. But we can and must expect more in terms of understanding and improving IBA delivery if we are paying for it.

It’s not just my own anecdotal experiences that suggest real world ‘IBA’ isn’t true to nature. Key researchers have called for more work here, and a recent Primary Care review stated: “On videotaped or observed interviews, alcohol-related discussions were often superficial and yielded little information regarding patients’ drinking practices.”

“Well, I don’t know what these [AUDIT] scores mean” – just another of the comments I’ve heard first hand from a GP! Of course some are doing it well, but I’ve little doubt these are a minority.

One crucial point though, its not really GPs we are talking about here as the key Primary Care IBA role, rather than Practice Nurses or Health Care Assistants. These are the people doing most new registrations and health checks. So when we talk about the issue of IBA in Primary Care, it isn’t really about GPs finding an extra 5 minutes in an already tight window, its about something that is supposed to be planned into other contacts.

Of course if someone is talking to their GP about a commonly alcohol linked issue – high blood pressure, depression, tiredness to name but a few – then IBA should be certainly be offered by the GP. But the real issue is the thousands of Practice Nurse or HCA contacts every day where the IBA box might be ticked on the system, but the actual intervention could be anything – and we’ve no way to tell. Or do we?

Holding practices to account?

The DES (Direct Enhance Service) alcohol contract has been criticised for not being robust enough by offering payment for screening only, following which brief advice ‘should’ be offered to at-risk drinkers. Perhaps saying ‘at-risk’ drinkers ‘should’ be offered brief intervention isn’t legally binding, but what about a basic duty of care? Furthermore, the current DES contract is clear that local ‘area team’ commissioners can and should hold practices to account:

Area teams are responsible for post payment verification. This may include auditing claims of practices to ensure that not only the initial screening was conducted but that the full protocol described in the enhanced service was followed i.e. that those individuals who screened positive on the initial screening tool were then administered the remaining questions of AUDIT and that a full AUDIT score was determined and that appropriate action followed, such as the delivery of brief advice, lifestyle counselling or where needed, referral to specialist services or assessment/screening for anxiety and/or depression

Where required, practices must make available to area teams any information they require and that the practice can reasonably be expected to obtain, in order to establish whether or not the practice has fulfilled its obligation under the ES arrangements.

So the current DES is clear. Doing AUDIT-C only and giving a leaflet to all risky drinkers isn’t in line with the contract. And commissioners have the right to ask practices to prove they are doing it properly. I’m well aware that good care and interventions mean less form filling and more time with the patient. But until the picture coming through is one of a better overall standard for IBA, practices should be required to demonstrate IBA is a person-centred intervention, not an opportunity to trigger a quick payment.

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In 2011 a ground-breaking document (in the IBA world at least) was released by a brilliant local service in Haringey. The document was a step-by-step guide to implementing the DES incentive scheme for IBA for new registrations in Primary Care. However what was arguably most impressive was the work revealing the local ‘DES picture’, which was not pretty reading.

The review found, to give just a few examples, that 75% of practices were using incorrect screening questions, and that only 50% of practices were offering face-to-face Brief Advice to identified risky drinkers. However such issues are likely to be commonplace if anecdotal reports and mystery shopping are anything to go by. The Haringey work though subsequently enabled action to significantly improve local IBA delivery.

So it seems apparent that the DES scheme itself does not result in good quality IBA – much more is needed to make that happen. Not a surprise really, but part of the problem has been a lack of available reports to identify this. Any new pieces of work evidencing local IBA experiences and action in relation to the DES are therefore to be welcomed.

A new case study – Cruddas Park Practice

I recently came across a valuable piece of work in the North East – a report from a pilot [pdf] which aimed to assess the practicality of implementing IBA into a busy GP practice. Again, this seemed to be the result of prior some work looking at the local picture. A survey of GPs carried out by Balance found that GPs were typically only addressing alcohol in response to clinical indicators, rather than routinely as IBA is intended. Time pressures and competing priorities were the recurring reasons offered for this.

The report provides a valuable insight into a local effort to properly implement IBA and supporting pathways into a busy GP practice. It looks at the compelling local need, and evidence base, but most of all, it gives a real insight into how perceptions and practice in relation to IBA can be changed by a relatively simple project.

Some of the best insights from the report related to the feedback from the staff who delivered IBA. It is always heartening to hear a busy practitioner relay a real life positive attitude to IBA, like this example:

“One guy had a health check and his cholesterol was up, he was drinking most days, now he has cut out drinking through the week. I told him his attitude was great. He had never thought about it until he came to the GP, he is sleeping better, he feels better. He thanked me and it made me feel good.”

Of course the reality is its not straightforward. This quote really captures probably the biggest overall challenge to IBA:

“Sometimes the timing is an issue, for people who screen mid way it’s not too bad, but if people score high you need to spend more time with them. It takes a double appointment – about 20 minutes. Or I add it into an annual check it takes an extra five minutes. It’s hard to judge how long it will take until you ask the questions. You definitely need longer – especially if they need to discuss the issues more, you don’t want to hurry people if they are listening.”

There is one issue I feel I should point out with the report itself. It suggested higher risk drinkers (16-19 AUDIT scores) were offered referral for advice or extended brief interventions as the main output, rather than offering ‘brief advice’ as a starting point and only then offering referral if needed or sought. The evidence doesn’t suggest EBI is superior to IBA for higher risk drinkers in most cases – see Clarifying Brief Interventions for more.

However the report is still a highly valuable and rare example of the type of attention that’s needed to convert patchy or inadequate IBA to a standard that really makes a difference. Good, simple IBA isn’t that hard after all.. is it?

I recently read a brilliant insight from Dr. Richard Saitz on the INEBRIA Google Group – he was commenting on a discussion about doctors objecting to IBA delivery on the grounds that it is ‘additional work’. His insight was:

“BUT I have never heard a physician object to doing an electrocardiogram or checking a blood pressure or listening to a heart or ordering a mammogram…So…”additional work” must be code for “additional work for a stigmatized problem” or for something about which people have attitudes about….”

As Richard is a doctor himself, this got me thinking about how we need to get into the psyche of doctors if we want them to implement IBA. That psyche is undoubtedly formed and normed throughout their lives and especially in education and early years of post-graduate training.

It reflects a wider problem I think which is a reluctance to accept a social model of health where a genuine curiosity about someone’s life and health is helpful in diagnosis and treatment (in the broadest sense). Why the emphasis on the physical? My experience is that doctors would love to have a (better) biomedical test for over-consumption of alcohol, even though screening tools are very good, non-invasive etc., because they really don’t want to have to talk to people about it…what does that say?

This reluctance, fear, distaste for actually communicating effectively with patients is very pervasive, and GPs who are very caring, lovely and wise still do not seek out people’s own story, their perspective, their ICE (ideas, concerns and expectations) in consultations as well as they could. Why? Well there are many reasons. But our research in the NHS found that they were not taught it, and even if they were, it was not modelled by others so it wasn’t valued/encouraged. Our system simply does not prioritise it. My guess is that the reason underpinning that is probably that we don’t have deep enough pockets to prove it helps, or failing that ‘market it’ anyway (as Pharma do).

So a reluctance to communicate effectively in general makes it hard to feel comfortable with an open conversation about alcohol that IBA really entails.

Your thoughts?

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Over recent years there has been a strong policy focus on IBA as a simple brief intervention: front-line roles giving simple feedback or ‘brief advice’ to risky drinkers. Big questions remain though over whether IBA is happening on the ground, or when it does, is it being done so effectively.

Another big issue though is whether Extended Brief Interventions (EBI) have been left in the shadow of simple IBA? However, since it seems most at risk drinkers will respond as well to IBA as EBI, why bother? A question perhaps strengthened by the SIPS trial which appeared to suggest even 5 minutes of brief advice is no superior to feedback and a leaflet.

However not everyone is content to take SIPS findings as word. Practically speaking , there are drinkers who need more than brief advice, but less than full ‘treatment’ offered by specialist services (which they are also less likely to engage with). Where someone either does not change following IBA, wants more help, is still unsure but does not need full structured treatment, EBI fills this potentially rather large gap of often ‘higher risk’ drinkers.

Another debate is of course whether EBI is actually a form of brief treatment rather than brief intervention. Semantics though are less important than identifying gaps in what’s currently being offered to all types of alcohol misusers. There are lots drinkers out there, maybe millions, who could arguably benefit from EBI or ‘brief treatment’ approaches, but very few will be offered or seek it.

How to increase access to EBI?

Of course EBI comes at a greater cost than IBA. It is part of the simple appeal of IBA that practically any front line role can do it with a quick bit of training or even e-learning. EBI however is an advanced skill based on Motivational Interviewing (MI) techniques, which are trickier than they sound. Most existing EBI services are therefore offered by alcohol roles working in community settings. However there are not many of these commissioned, although the case is there in the NICE alcohol guidance. (see 3.1 of the costing report in particular).

In some cases though other roles are stepping in, such as health trainers, ‘coaches’ or other independent practitioners working through GP practices. Certainly Primary Care settings seem the most logical arena for taking EBI to those that might benefit from it.

Avoiding ALCOHOL in the service name?

One further key consideration about EBI or ‘brief treatment’ approaches is that drinkers may often be wary of engaging in any form of ‘treatment’ or intervention. Many people view alcohol misuse as only applying to dependency, often at the more severe end, and so are unfamiliar with the concept of ‘risky’ or harmful use.

As a result, many EBI or other alcohol services have been wise to market themselves as services that are about helping people make healthier choices. This clearly fits well with the psychosocial nature of addressing alcohol misuse, but at the same time people need to understand what the service is really about.

One final plus

One further benefit of having EBI roles available is the impact on IBA delivery. EBI roles can play a crucial leadership role in ensuring routine identification is taking place by primary care roles, as well as being there as a referral resource for those otherwise left with not more than a leaflet to help them cut down.

In conclusion, the case and method for improving EBI acces is less straightforward than for IBA. Yet there is still a clear need and cost benefit to increasing access to interventions offering more than brief advice and less than structured treatment. More real world learning is needed on the best ways to achieve this.

I’m not going to try and summarise the results here – the BMJ article is easy enough to garner and a Findings bulletin also interprets them in a simplified form. Instead I wish to consider some implications for those interested in delivering IBA.

However I should point out that I will be writing on the assumption that SIPS findings did show that brief intervention is effective. But I certainly expect to return to the discussion that this may not be the case. These charges are not so much based on a question of brief intervention efficacy, but whether SIPS can be seen to validate effectiveness in real world settings.

So assuming we accept the SIPS findings as evidence that brief interventions can be effective in practice, I will explore some key implications. Not surprisingly, of headline interest is the finding of no significant difference in outcome between the 3 intervention approaches tested (all 3 showed a reduction at 6 at 12 months). The three main intervention approaches were:

Level 2 might be considered standard IBA, with 1 being the most minimal intervention, and 3 being more ‘extended’ brief intervention. So do SIPS findings suggest that “less is more”?

To some degree it would seem so, but they DO NOT suggest that giving out a leaflet is all that’s needed. Crucially, the simplest intervention included ‘feedback’ in addition to the leaflet. Feedback generally means informing a person that their answers to the screening question suggests their drinking places them at risk. Often we teach people to follow this with “How do you feel about that?”, encouraging contemplation and often leading nicely into ‘brief advice’. So is ‘advice’ beyond feedback unnecessary?

In many cases, simple screening + feedback and leaflet could well be enough as the trial suggests. However, although we have a lot of evidence that IBA works in Primary Care, there is still relatively little known about how. It it is probable though that IBA works largely by triggering at-risk drinkers to start to think about their drinking, rather than the element of helping them to cut down (e.g. brief advice or leaflet).

To me this makes sense; we know well that IBA is based on the ‘stages of change’ behaviour change theory where ‘contemplation’ about whether a behaviour (smoking/diet/exercise/drinking) is crucial as the start of the process. So can we really forget about offering brief advice or extended brief motivational approaches?

With all these things, there is a risk of a reductionist ‘one size fits all’ approach. Many risky drinkers will not be wanting ‘advice’ straight after being told something that could have come as a bit of a shock. Their ‘contemplation’ phase may well need some time to process.

Sometimes though, a person may move quickly into ‘preparation’ (i.e. deciding to cut down), or already be thinking about it and welcome some help. Perhaps because these people are smaller in number, the benefit of brief advice in SIPS did not come out as statistically significant. We must also note previous studies have shown the benefit of advice or ‘brief counselling’ over no intervention.

So common sense should apply to IBA delivery in many ways – make sure proper screening is followed with ‘feedback’ (not just a leaflet), and if someone seems to want some help, there’s a good chance they’ll appreciate it. One further finding that was statistically significant in SIPS was that patients receiving the longest intervention were most positive about their experience with the practitioner.

I think the results can be seen as good news if we accept them at face value. In many cases, IBA may commonly only require the shortest and easiest forms of “advice”- feedback and a leaflet. Sometimes a bit more may be helpful, but it is nothing new to suggest asking the questions in the first place is what really counts. The debate about how we interpret the SIPS findings is probably just beginning.